Trauma Informed Care Children of Trauma 42855 Garfield Road, Suite 111 Caelan Kuban, PsyD , LMSW Clinton Township, MI 48038 877.306.5256 | www.starrtraining.org/tlc [email protected] Agenda • Major differences between grief and trauma • Trauma as an experience • Trauma/Delinquency Link • DSM issues • How to Help • Case Examples What is TLC? TLC is a program of Starr Commonwealth/Starr Global Learning Network 6,000 Certified Trauma Specialists across the country Trauma Intervention Programs and Resources for traumatized children, adolescents, parents, schools, agencies and communities. Training/Online Courses/Parent Trauma Resource Center Certification What is Trauma Informed Care? What happened to you? NOT What is wrong with you? Trauma intervention is an essential part of treatment because of: the impact trauma can have on the way a child views themselves and the world around them the impact trauma has on a child’s emotions, behavior, learning, and their ability to interact with others Trauma Informed Care We know that kids who have experienced trauma often require unique care and an individualized treatment approach. Major Differences Between Grief and Trauma The ONE WORD that best describes each Grief Trauma GRIEF TRAUMA GeneralizedThe Differences reaction is SADNESS Generalized reaction TERROR Grief reactions stand ALONE Trauma reactions generally include grief reactions Known to public and professionals Largely unknown (esp. in children) Does not disfigure identity Attacks and distorts identity Regret - “I wish I would have…” Guilt – “ It was my fault” Dreams of person who died, was hurt Dreams of self dying, being hurt Pain is related to the loss Pain is related to tremendous terror and sense of powerlessness, fear and loss of safety Anger is not destructive Anger is assaultive (even if non-violent trauma) Trauma Any experience that leaves a person feeling hopeless, helpless, fearing for their life/survival, their safety. Examples?? Important to remember – it is a person’s perception, their experience not ours that makes something traumatic. Divorce may be more traumatizing than suicide or incarceration. Keep in Mind Trauma reactions are no different following non-violent situations such as natural disasters, chronic illness etc. Back To Back Trauma Exposure Surviving victim (abuse, neglect, car accident) Witness (personal witness – domestic violence, police, fire) Related to (peer, siblings – of chronically ill siblings, sibling that completed suicide) Listening to details of trauma (therapists, media exposure, video games etc.)* Children’s Hospital Video DSM-IV-TR (2005) Remember that the APA just started including children under this PTSD diagnosis within the past 15 years. 3 subcategories of PTSD Re-experiencing Avoidance Arousal Also, if these symptoms and reactions are noticed during the first 4 weeks following a traumatic incident – it is normal. It isn’t until after that time we would consider PTSD if these symptoms and reactions were still observable/reported. Posttraumatic Stress Disorder Reexperiencing Avoidance Arousal Flashbacks Dissociation Cognitive Dysfunction Intrusive Thoughts Detachment/Numbing Hypervigilence Images Not wanting to talk about it Attachment Reaction Traumatic Dreams Diminished Interests Startle Responses Difficulty Sleeping OCD-like behavior Sleep Difficulty Physiological Reactions – Phobic-like behavior Irritability Headaches, etc. Self-harm Aggression Substance Abuse Assaultive-like behavior Eating Disorders Inattention Posttraumatic Stress Disorder (DSM 5) Re-experiencing Avoidance Negative Arousal Cognitions and Mood Flashbacks Detachment Distorted sense of Aggression self Intrusive thoughts Numbing Estrangement to Reckless behavior -images others Traumatic dreams OCD like behavior Markedly Self-destructive Phobic like diminished interest and behavior Rule-breaking behaviors Sleep problems Self Harm Depression Hypervigilence Physical Substance Abuse Blames self or Irritability complaints others Eating Disorders Inattention Not wanting to talk Cognitive/Learning about it problems DSM-5 Additions (1) a pre-school subtype for children six and under- Posttraumatic Stress Disorder in Preschool Children, (2) PTSD with prominent dissociative symptoms (feeling detached from one’s own mind or body – experiences that seem unreal or dreamlike) Chris and Boo Video Developmental Trauma Disorder DTD (Bessel van der Kolk, Robert Pynoos) 2009 Proposed Diagnostic Category for DSM-5 “Whether or not they exhibit symptoms of PTSD, children who have developed in the context of danger, maltreatment and inadequate care giving systems, are ill served by the current diagnostic system, as it frequently leads to……. DTD Continued …no diagnosis multiple unrelated diagnoses, an emphasis on behavioral control (meds) without recognition of interpersonal trauma and lack of safety in the etiology of symptoms, and a lack of attention to ameliorating the developmental disruptions that underlie the symptoms.” Bessel van der Kolk, MD; Robert Pynoos, MD; et al. February, 2009 Let’s Label That Behavior ODD ADDICT CONDUCT DISORDER ADHD BIPOLAR DISORDER ADD BORDERLINE Short and Long Term Effects of Trauma We see twice the number of serious health and mental health problems as those without a history of trauma. Chronic fatigue Poor Immune function Eating Disorders & Obesity Hypertension Interpersonal difficulties Aggressive behavior Low self-esteem Depression Anxiety 94 billion dollars per year (economic costs of trauma) ACE Study - http://www.cdc.gov/ace/ The Adverse Childhood Experiences (ACE) Study is one of the largest investigations ever conducted to assess associations between childhood maltreatment and later-life health and well- being. More than 17,000 participants Findings suggest that certain experiences are major risk factors for the leading causes of illness and death as well as poor quality of life in the United States. ACE STUDY ACE STUDY Trauma and Adjudication Link Youth that are part of the juvenile justice population have a significantly higher incidence of trauma. Over 90% of juvenile detainees report at least one traumatic event. The occurrence of multiple complex trauma is frequently reported among incarcerated youth. Trauma and Adjudication Link The US Department of Justice reports that children exposed to violence are at higher risk of engaging in criminal behavior. According to the Michigan Juvenile Justice Collaborative, child abuse and neglect increases the risk of arrest as a juvenile by 55% and increases the risk of being arrested for a violent crime as a juvenile by 96% In 2007 Michigan law enforcement officials arrested nearly 45,000 juvenile offenders. National Survey for Child and Adolescent Well-being Significant relationship between maltreatment and delinquency was found in data collected from 1,200 youth. Youth at greater risk of maltreatment experienced higher levels of internalizing symptoms and result in increased risk for delinquent behaviors. Connection: Trauma and Delinquency Interpersonal violence exposure increases risk for PTSD symptoms, depression, binge drinking and delinquency (Cisler et al., 2012). Multiple trauma exposure – increased risk for violence perpetration (Duke et al., 2010). Family conflict, school isolation increase vulnerability to delinquency (Ford et al., 2006). The disruption in emotional regulation can result in increased delinquency rates. Dysregulation and Trauma Dysregulated affect is a central feature in both PTSD and juvenile delinquency (Ford et al., 2006). Heightened emotional states Limited understanding about emotions Reactivity or sensitivity about specific emotional states Maladaptive management tactics for emotional episodes Chronic trauma leads to difficulties with the identification and labeling of emotions. Acute Stress vs. Post traumatic Stress Acute Stress – NORMAL Response/Reaction to stress and even trauma – 4-6 weeks Posttraumatic Stress – Exaggerated and Prolonged Stress Response beyond 4-6 weeks and even years later Dysregulation of Stress Chemistry – Stress hormones don’t come back down Increased activation of the Sympathetic Nervous System (heart rate, startle response, fight response) Trauma is a Sensory Experience Trauma is a because of what happens to the brain and memory during trauma. The Brain Because Trauma Is A Sensory Experience… • We must use SENSORY INTERVENTIONS to help relieve the pain and terror associated with the trauma. • REMEMBER, there are no words, only images, sensory memories of a trauma. • So when A person “doesn’t want to talk about it” many times it is more like…”they can’t”. • Also, a person may not “remember” their experience but you can still work on a sensory level with them. Trauma vs. Healthy Brain Ghosts in the Nursery (Reflection) Experience becomes Biology Though it may be difficult to believe, one traumatic event in any one’s life, especially a child’s, can alter both the structure and the chemistry of the brain. We Are Wired To Connect – This Emotional Life Attachment gone wrong The maturation of the brain is heavily mediated by interactions and the attachment relationship with the primary caregivers. Attachment experiences directly influence optimal brain development (including maturation of the right brain – development of coping responses – if not taught, will not learn) Stressed vs. Secure Attachments Stressed Attachments Secure Attachments Chaotic biochemical changes Growth facilitating environment Interfere with brain’s coping Strong Neuronal Connections mechanisms Integrates